IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 8 Ver. IV (Aug. 2014), PP 53-59
www.iosrjournals.org

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

Aalap Prajapati1, Anchal Prajapati2, Dhawal R.Mody3, Anuraag B.Choudhary4
1

Department of Prosthodontics, Pramukh Swami Medical College, Karamsad, Anand, India-388325

2
Department of Periodontics, Pramukh Swami Medical College, Karamsad, Anand, India-388325
3
Department of Periodontics, VSPMs Dental College, Hingna road, Nagpur, India- 440019
4
Department of Oral Medicine, VSPMs Dental College, Hingna road, Nagpur, India- 440019

Abstract: Computer Aided Design/Computer Aided Manufacturing (CAD/CAM) was first introduced to
dentistry in the mid-1980s.Both chairside and chair sidelaboratory integrated procedures are available for
CAD/CAM restoration fabrication. In selecting which procedure to follow, consideration should be given to
esthetic demands, chairside time, and laboratory costs, number of visits and convenience and return on
investment associated with CAD/CAM equipment. Depending on the method selected, CAD/CAM ceramic
blocks available for restoration fabrication include leucite reinforced ceramics, lithium disilicate, zirconia, and
composite resin. In order to determine which type of ceramic to use, the practitioner must take into account
esthetics, strength, and ease of customizing milled restorations. This article provides an overview of various
CAD/CAM systems.
Keywords: CAD-CAM, leucite reinforced ceramics, zirconia

I.

Introduction

The latest innovations in TECHNOLOGY made almost all things possible in this world. The lost-wax
precision casting of gold alloys, dough modelling and curing of acrylic resins and powder sintering of dental
porcelains were originally developed for dentistry and are well established as conventional dental laboratory
technologies. It is without doubt that high quality dental devices can routinely be fabricated through the
collaboration of dentist and dental technicians. Nevertheless, dental laboratory work still remains to be labourintensive and experience dependent.1 The laboratory technicians primary role in dentistry is to perfectly copy
all of the functional and aesthetics parameters that have been defined by the dentist into a restorative solution. It
is an architect/builder relationship. Throughout the entire restorative procedure, from initial consultation through
treatment planning, provisionalization and final placement, the communication routes between the dentist and
the dental technician require a complete transfer of information pertaining to existing, desired and realistic
situations and expectations to and from the clinical environment. Functional components, occlusal parameters,
phonetics and aesthetics are just some of the essential information which dental technician completes with his
skills and experience. As dentistry evolves into the digital world of image capture, computer design, and the
creation of dental restorations through robotics, the dental laboratory must evolve as well. Computer-aided
design/Computer-aided manufacturing (CAD/CAM) restoration gives us that option. The laboratory is no longer
a place; it is instead to a large degree, virtual and fluid entity. 2 It is hence no doubt to call CAD/CAM a Virtual
Laboratory. (Fig. 1)
Research and development of dental CAD/CAM systems has been actively pursued world-wide since
1980s due to continuous efforts of three pioneers namely, Dr. Francois Duret, Dr. Werner Mormann and Dr.
Andersson.3

II.

General Principles Of Cad/Cam Technology

The developments that have fuelled the growth of the CAD/CAM dentistry are mostly based on the
major developments in microelectronics, which have helped in leapfrogging the capabilities. For convenience in
understanding, CAD/CAM system is divided into CAD/CAM hardware and CAM/CAM software. 4
Cad/Cam Hardware 7
Memory Central Processing Unit (CPU) Input device

Output device
CAD/CAM SOFTWARE: (Fig. 2)
Prosthesis is fabricated by CAD/CAM technology through three basic steps8:

www.iosrjournals.org

53 | Page

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

Digitization
The digitizing accuracy is a major factor, which has an influence on the fit of fixed restoration.
Currently the data acquisition is either performed directly in the patients mouth (intraoral) or indirectly after
taking an impression and fabricating a master cast (extraoral). Regardless of the digitizing mode applied, clinical
parameters, e.g. saliva, blood, movements of the patient, might affect the reproduction of teeth.
Intraoral digitization allows the dental care provider to directly obtain the data from the prepared
teeth. Thus, taking an impression and fabricating a cast model are no longer necessary. Titanium dioxide or
magnesium oxide powder has to be applied to the glossy, lucent tooth surfaces in order to avoid reflections and
to create a measurable surface. The powder layer applied to the tooth surface results in an additional thickness of
13-85 m. An in vitro study showed a higher accuracy of the extraoral digitization than in case of intraoral one 9.
There are two methods available for extraoral digitization.
1. Contact digitization
2. Optical digitization
Accuracy is the degree of veracity, e.g. how well the measured value represents the truth, while precision is
the degree of reproducibility, e.g. the repeatability of the measurement system. Ideally a measurement device is
both accurate and precise, with measurements all close to and tightly clustered around the true value10.
Mathematical Processing Or Computer-Aided Designing (Cad). (Fig. 3-7)
A three-dimensional image of the die is produced over the screen and can be rotated for observation
from any angle. Current software allows the crown form to be designed by selecting the proper tooth element
from the library and then modelling the crown to fit in with the remaining dentition.
Computer-Aided Milling (Cam)5
The CAM technologies can be divided in three groups according to the technique used:
a. Subtractive technique from a Solid Block The CAM technique most commonly applied in
manufacturing frameworks for single crowns and FPDs is to cut the contour out of an industrially
prefabricated solid block of different materials. The size of the material blocks available for the milling
units limits the size of the FPDs.
b. Additive technique by applying Material on Die Here in this technique Alumina or Zirconia is dry
pressed on the die and the temperature is raised to a temperature similar to the presintering state. At this
stage, enlarged and porous coping is stable. Its outer surface are milled to the desired shape and coping,
removed from die, and sintered into the furnace for firing to full sintering.
c. Solid free form fabrication This category includes new technologies originating from the area of
Rapid Prototyping (RP), which have been adapted to the needs of dental technology. A second
technology originating from rapid prototyping is the stereolithography (Perfactory, Delta Med,
Frieberg, Germany). In this technique, the restoration is produced from light sensitive plastic, which
can be converted into any desired alloy with the casting technique. Occlusal splints and diagnostic
templates for oral implantology can also be produced with this technique. The third technique is the
selective laser sintering, where sinterable powder materials are built up to form 3-D restorations.
The milling device consists of two major units: (1) rotatory drilling element with interchangeable
bores of different shapes and diameter and computerized velocity (2) a mobile platform to which the dummy is
fixed. The computerized platform can be moved in three dimensions, allowing precise milling of the desired
coping.
Milling consists of three steps: (1) rough milling inside the coping to remove the bulk of the material
(2) fine inside milling to increase accuracy (3) rough external milling.
Production Factors
The range of accuracy for each step is 3-5m for digitizing, less than 5m for mathematical processing
and 15-25m for milling. Overall accuracy can be increased by carrying out the individual steps more slowly.
Theoretically, the mean working times of the different procedures are 3-8 minutes for digitizing, 8-12
minutes for mathematical processing and 20-25 minutes for milling. It should be emphasized that the actual
working time is approximately 10 minutes, mainly for digitizing.
Commercially Available Cad/Cam Systems
CAD/CAM systems may be categorized as either in-office or laboratory systems. Among all dental
CAD/CAM systems, CEREC is the only manufacturer that provides both in-office and laboratory modalities.
Laboratory CAD/CAM systems have increased significantly during the last 10 years and include DSC Precident,
Procera, CEREC inLab, Lava and many others.
www.iosrjournals.org

54 | Page

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

Cicero System11
Cerec System13
Evolution Of Cerec System12

III.
YEAR

HARDWARE

1980

Figures And Tables

RESTORATION TYPE

DEVELOPER

Basic concept

SOFTWARE
CAPABILITY
Two dimensional

Inlays

1985

CEREC 1

Two dimensional

First chairside inlay

1988

CEREC 1

Two dimensional

1994

CEREC 2

Two dimensional

2000

CEREC 3 & inLab

Two dimensional

2003

CEREC 3 & inLab

Three dimensional

2005

CEREC 3 & inLab

Three dimensional

Inlays(1), Onlays(2) and

Veneers(3)
1-3, partial(4) and full(5)
crowns, copings(6)
1-6 and three-unit bridge
frames
1-6 and three & four-unit
bridge frames
1-5 and automatic virtual
occlusal adjustment

Mormann (University of
Zurich) and Brandestini
(Brandestini Instruments,
Zurich)
Mormann
and
Brandestini
Mormann
and
Brandestini
Sirona
(Munich,
Germany)
Sirona
(Bensheim,
Germany)
Sirona
Sirona

Fig.1 An overview of the CAD/CAM systems available today in dentistry.

www.iosrjournals.org

55 | Page

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

Fig. 2 PATHWAY THE CURRENT CAD/CAM SYSTEM USES FOR FIXED PROSTHESIS
FABRICATION

Fig. 3 Die With Black And White Contrast

FIG. 4 COMPUTER GRAPHIC PRESENTATION OF SCANNED DIE

www.iosrjournals.org

56 | Page

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

FIG. 5 DESIGNED CROWN PLACED IN ROW

FIG. 6 DESIGN CROWN IN OCCLUSION

FIG. 7 MILLING PROCEDURE

www.iosrjournals.org

57 | Page

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

Lava System (3m Espe, Seefeld, Germany) 3
Procera System
Katana System1
Celay System 14
Everest System3
Cercon System3
Dcs Precident3
Other Dental Cad/Cam Systems15
3. ZENOTec (Wieland Dental & Technik GmbH & Co KG)
4. Hint-ELs DentaCAD system (Hint-ELs, Griesheim, Germany)
5. Cerasys (Cerasystems, Buena Park, CA)
6. Wol-Ceram (XPdent corporation, Miami, FL)
7. BEGO Medifacturing (BEGO Medical GmbH, Bremen, Germany)
8. Turbodent System (U-Best Technology Inc, Anaheim, CA)
9. Etkon system (etkon USA, Arlington, TX)
10. iTero (Cadent, Carlstadt NJ, US)
Comparision Of Common Dental Cad/Cam Systems3
SYSTEM
Cerec 3

MARKET
LAUNCH
2000

PROCESS
CENTRE
Chairside

SCANNING
MECHANISM
Optical

Cerec InLab

2001

Dental Lab

Laser

DCS Precident

1989

Dental Lab

Optical

Procera

1993

Manual

Lava

2002

New Jersey or
Sweden
Dental Lab

Everest

2002

Dental Lab

Optical

Cercon

2001

Dental Lab

Laser

Optical

CAD PROGRAM

CAM PROCESS

Yes, custom
database
Yes, custom
database
Yes, custom
database
Yes, custom
database
Yes, custom
database
Yes, custom
database
No

Fully
automatic
Fully
automatic
Fully
automatic
Fully
automatic
Fully
automatic
Fully
automatic
Fully
automatic

design and
design and
design and
design and
design and
design and

Advantages And Disadvantages Of Cad/Cam Technology

Advantages:
The advantages of using CAD/CAM technology can be summarized as: 1,16
1. Applications of new materials High strength ceramics that are expected to be the new materials for
FPDs frameworks have been difficult to process using conventional dental laboratory technologies.
Therefore, this challenged to apply CAD/CAM processing. Due to successful use of all-ceramic
crowns, all ceramic systems have become a viable treatment option 6.
2. Time effectiveness
3. Reduced labour
4. Quality control
5. Patients often experience irritation in, sensitivity in and/or difficulty in cleaning temporized teeth. With
this system temporaries become obsolete, thus making uncomfortable and unaesthetic transition times a
thing of past. Also, there is diminished chance of bacterial invasion during this phase, decreased pulpal
stress resulting from excessive cleaning, drying or trauma, and decreased need for the additional tooth
manipulation.
6. It is not always possible for the dentist to create a full arch of precisely parallel preparations. The
computer can calculate, design, and build the copings, which can be cemented to yield a well-seating
bridge.
7. Scanning an image and viewing it on a computer screen allows the dentist to review the preparation
and impression, and make immediate adjustments to the preparation and/or retake the impression if
necessary, prior to its being sent to the milling unit or a laboratory. This ensures no calls from a
laboratory that the impression is defective. This review, as well as seeing a preparation multiple times
its normal size on a screen, can result in improved preparations.
8. A digital impression also means that patients do not have to have impression material and trays used,
saving them discomfort.
9. By using zirconium as implant abutment, light transmission into the gingival sulcus is allowed, thus
preventing the grey of opaque metal parts from showing through peri-implant tissue.
www.iosrjournals.org

58 | Page

Dentistry Goes Digital: A Cad-Cam Way- A Review Article

10. Latest innovation in CAD/CAM system allows occlusion to be viewed and developed in dynamic
state.
Disadvantages: 1,16
1. The primary consideration in a CAD/CAM purchase is the length of the learning curve, which may
range from a few days to several months and may result in the loss of office production and loss of
patient treatment time.
2. Other major problem is the potential for the dental team to resist the systems use and the clinicians
lack of confidence in using a computerized system.
3. Capital costs of these systems are quite high and rapid large scale production of good quality
restoration is necessary to achieve financial viability.
4. Matching the patients tooth shade to the blocks of materials used to fabricate the restorations can be a
challenge to the dentist initially.
5. Some CAD/CAM system relies on margin capture for digitization, thus making subgingival margin
capture challenging.
6. CAD/CAM is ever advancing technology. Upgrades and updates are to be expected. The existing
software takes no time to become obsolete. It is wise to question how long the technology has been on
the market and how soon a revision will become available. Thus, the dentist may need to budget for
monthly expenses for technical support and software upgradation.

IV.

Conclusion

With growing awareness of aesthetics and biocompatibility, patients increasingly request metal free
restorations. Due to successful use of all-ceramic crowns, all ceramic systems have become a viable treatment
option7. These newer materials also are more wear resistant nearly like enamel and are strong enough for full
crowns and bridges. The application of dental CAD/CAM systems is promising, not only in the field of crowns
and FPDs, but also in other fields of dentistry. There is no doubt that the application of CAD/CAM technology
in dentistry provides innovative, state-of-art dental service, and contributes to the health and Quality of Living
of people in aging societies. As Duret concluded The systems will continue to improve in versatility, accuracy,
and cost effectiveness, and will be a part of routine dental practice in coming time.3

References
[1].
[2].
[3].
[4].
[5].
[6].
[7].
[8].
[9].
[10].
[11].
[12].
[13].
[14].
[15].
[16].

Takashi M, Yasuhiro H, Jun K, Soichi K. A review of dental CAD/CAM: current status and future perspectives from 20 years of
experience. Dental Materials Journal, 2009: 28(1): 44-56.
Lee C, Alex T. CAD/CAM Dentistry: A new forum for dentist-technician Teamwork. Inside Dentistry, Sep 2006: vol 2, Issue 7.
Perng-Ru Liu. Panorama of Dental CAD/CAM Restorative systems. Compedium, July 2005: 26(7): 507-512.
Angeles M, Salvador A, Mariano A, Maria P. CAD/CAM dental systems in implant dentistry: Update-Med Oral Patol Oral Bucal:
March 2009 1:14(3), E141-5.
Candice Z, Shermian A, Richard M, John D. Rapid prototyping technique for creating a radiation shield. J Prosth Dent, April 2007:
97(4): 236-41.
Vigolo P, Odont D, Fonzi F. J Prosthodontics, 2008: 17: 621-26.
CAD/CAM: Principles, practice and manufacturing management. 2 nd edition: Part-I.
Samet N, Benjamin R, Shaul G, Noah S. A CAD/CAM system for the production of metal copings for porcelain fused to metal
restorations. J Prosth Dent 1995: 73(5): 457-463.
Sebastian Q, Heike R, Ralph G. Direct mechanical data acquisition of dental impressions for the manufacturing of CAD/CAM
restorations. J of Dentistry 2007: 35: 903-908.
Persson A, Matts A, Agneta O, Gunilla S. Computer aided analysis of digitized dental stone replicas by dental CAD/CAM
technology. Dental Materials 2008: 24: 1123-1130.
Jef M, Simon V, William J, Carel D. The CICERO system for CAD/CAM fabrication of full-ceramic crowns. J Prosth Dent 2001:
85(3): 261-267.
Mormann W. The evolution of the CEREC system. JADA 2006: 137: 7S-13S.
Wang WC, McDonald A. Petrie A, Setchell D. Interface dimensions of CEREC-3 MOD onlays. Eur J Prosthodont Rest Dent 2007:
15(4): 183-189.
Rinke S, Huls A, Jahn L. Marginal accuracy and fracture strength of conventional and copy-milled all ceramic crowns. Int J
Prosthodont 1995: 8: 303-310.
Feuerstein P. New changes in CAD/CAM: Part 2 Lab systems. Inside dentistry. March 2007: 82-86.
Paul F, Sameer P. CAD/CAM and digital impressions. Catalogue of the course organized by Pennwell.

www.iosrjournals.org

59 | Page